Lessons from a Pioneer ACO

When the Centers for Medicare and Medicaid Services launched the "Pioneer model" of an accountable care organization (ACO), Atrius Health jumped at the opportunity to participate. Being part of this new model gave us access to valuable data about our Medicare patients, allowing us to provide the holistic, patient-centered care we believe is the foundation of healthcare transformation.

While there is always more to learn, thus far we've gained valuable insight into two key areas:

Embracing a Population Health Approach

Medicare covers some of our most vulnerable patients; those for whom care has been most fragmented. We saw participation in the Pioneer ACO as an opportunity to evolve a population health approach for Medicare-eligible patients, regardless of the payer. Using our data warehouse, which integrates claims data and electronic health records (EHR), we work to identify gaps in care and opportunities for improvement. Using this data has allowed us to tailor care plans to our patients' complex medical needs. A multidisciplinary care team conducts monthly "roster reviews" of our highest risk patients to ensure their care is comprehensive, meets their goals, and connects them to the right clinical and care management programs.

Integrating Medicare data into our population health strategy has allowed us to create guidelines for more effective care that can be implemented across our practice sites. For example, participating in the Pioneer ACO model gave us a more complete picture of patients with chronic kidney disease (CKD), which often goes under-recognized in its early stages. When we dug into integrated claims and clinical data, we found we could diagnose CKD in earlier stages of the disease and refer patients to nephrologists sooner -- a practice we feel will improve outcomes.

We embarked on a multifaceted initiative to review claims data and determine where our patients were seeking treatment for CKD. We engaged our nephrologists, who treat a high volume of Atrius Health patients, and assembled a multi-disciplinary workgroup to develop CKD clinical guidelines. The guidelines include trainings and education programs to help clinicians recognize and manage the disease; tools in our EHR to assist clinicians in the exam rooms; and educational materials that we provide to CKD patients.

In addition, new primary care physicians receive an orientation on our CKD guidelines, and we regularly share data among care teams to help identify patients who may be at risk for CKD based on their lab results.

In 2014, 78% of patients identified as at-risk for CKD had the diagnosis on their problem list as compared with 52% before we started this work. While improved outcomes, such as reduced need for dialysis, will take much longer to measure, having CKD identified as a risk factor earlier makes it more likely that patients will receive earlier treatment, improving care for this population over time.

Engaging Patients, Providers Around End-of-Life Care

Conversations about engaging patients in their care has taken center stage in the healthcare community's work to provide high quality care at an affordable cost. At Atrius Health, we believe the key marker of patient-centered care is how well we do as a healthcare system honoring patient's goals and preferences for care at the end of life. When we prioritized this work, we did some baseline reporting and learned we could improve upon the way we documented our patients' wishes in the EHR so that the entire care team could access them. We solved that discrepancy by improving how we engage with patients in conversations to understand their goals.

Discussing care at the end of life can be uncomfortable for patients and providers. We conducted a series of internal trainings to help primary care physicians and care team members engage patients in discussions about advance care planning during the course of routine care. Our internal trainers, whom we call Advance Care Planning Champions, use video presentations, interactive sessions, and role playing as a means of strengthening clinician core competencies in initiating conversations with patients about end-of-life care.

The Advance Care Planning Champions serve as local mentors who can be a resource to colleagues about the four steps of the advance care planning process:

1. Prepare for the discussion by clarifying the patient's current health status and prognosis

2. Introduce the concept of advance care planning as routine medical care and options for care in the context of the patient's current health status and prognosis

3. Document the patient's goals of care into specific medical orders in the patient's medical record

4. Apply and honor these goals, revisiting them as appropriate as patients' health status and treatment preferences change

We have multidisciplinary palliative care teams, which include specially trained physicians and advance practice clinicians, case managers, home care nurses, chaplaincy, and social work disciplines, that collaborate with the patient's primary care physician to meet the complex needs of patients and families with advanced illness. The team treats symptoms and facilitates advance care planning, while also providing psychosocial support through family meetings, bereavement care, and referral to hospice when appropriate.

More than 80% of Atrius Health primary care physicians, physician assistants, nurses, and other care team members have completed this training. As a result, we have seen a significant increase in documentation of patient wishes as well as designation of a family member as a healthcare proxy.

We have opened a line of communication so that clinicians and practices can learn from each other and continue to look at best practices across the system. Looking forward, we will continue to offer more training opportunities to educate our staff about hospice care options, eligibility requirements, covered benefits, and the role primary care physicians can play in this setting. Dealing with such a delicate topic is difficult, but advance care planning is necessary to true patient-centered care.

At Atrius Health, we believe that value-driven, accountable, coordinated care is the sustainable model for the future. Participating in the Pioneer ACO has allowed us to build on that belief and improve care for our patients. As an industry, we have come a long way but there is still much that can be done to learn and improve for our patients.

Emily Brower is Vice President of Population Health at Atrius Health, the Northeast's largest nonprofit independent physician-led healthcare organization. For the past 3.5 years, she has led the Atrius Health effort as a Pioneer ACO.

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